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Abdulelah M, Haider O, McAuliffe M, Al-Faris L, Paadam J, Medarametla V, Kleppel R, Joshi K. Do Decision Support Tools Decrease the Prevalence of Hospital-Acquired Venous Thromboembolisms When Compared to Clinical Judgement? A Single-Center Pre-Post Study. J Clin Med 2024; 13:3854. [PMID: 38999420 PMCID: PMC11242558 DOI: 10.3390/jcm13133854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2024] [Revised: 06/23/2024] [Accepted: 06/27/2024] [Indexed: 07/14/2024] Open
Abstract
Introduction: Hospital-acquired venous thromboembolisms (HA-VTEs) carry a significant health burden on patients and a financial burden on hospitals due to reimbursement penalties. VTE prophylaxis at our institute was performed through utilizing an order set based on healthcare professionals' perceived level of risk. However, the use of standardized risk assessment models is recommended by multiple professional societies. Furthermore, integrating decision support tools (DST) based on the standardized risk assessment models has been shown to increase the administration of appropriate deep vein thrombosis (DVT) prophylaxis. Nonetheless, such scoring systems are not inherently flawless and their integration into EMR as a mandatory step can come at the risk of healthcare professional fatigue and burnout. We conducted a study to evaluate the incidence of HA-VTE and length of stay pre- and post implementation of a DST. Methods: We conducted a retrospective, pre-post-implementation observational study at a tertiary medical center after implementing a mandatory DST. The DST used Padua scores for medical patients and Caprini scores for surgical patients. Patients were identified through ICD-10 codes and outcomes were collected from electronic charts. Healthcare professionals were surveyed through an anonymous survey and stored securely. Statistical analysis was conducted by using R (version 3.4.3). Results: A total of 343 patients developed HA-VTE during the study period. Of these, 170 patients developed HA-VTE in the 9 months following the implementation of the DST, while 173 patients were identified in the 9 months preceding the implementation. There was no statistically significant difference in mean HA-VTE/1000 discharge/month pre- and post implementation (4.4 (SD 1.6) compared to 4.6 (SD 1.2), confidence interval [CI] -1.6 to 1.2, p = 0.8). The DST was used in 73% of all HA-VTE cases over the first 6 months of implementation. The hospital length of stay (LOS) was 14.2 (SD 1.9) days prior to implementation and 14.1 (SD 1.6) days afterwards. No statistically significant change in readmission rates was noted (8.8% (SD 2.6) prior to implementation and 15.53% (SD 9.6) afterwards, CI -14.27 to 0.74, p = 0.07). Of the 56 healthcare professionals who answered the survey, 84% (n = 47) reported to be dissatisfied or extremely dissatisfied with the DST, while 91% (n = 51) reported that it slowed them down. Conclusions: There were no apparent changes in the prevalence of HA-VTE, length of stay, or readmission rates when VTE prophylaxis was mandated through DST compared to a prior model which used order sets based on perceived risk. Further studies are needed to further evaluate the current risk assessment models and improve healthcare professionals' satisfaction with DST.
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Affiliation(s)
- Mohammad Abdulelah
- Department of Internal Medicine, University of Massachusetts Chan Medical School—Baystate Regional Campus, Springfield, MA 01199, USA (R.K.)
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Turner BR, Machin M, Salih M, Jasionowska S, Lawton R, Siracusa F, Gwozdz AM, Shalhoub J, Davies AH. An Updated Systematic Review and Meta-analysis of the Impact of Graduated Compression Stockings in Addition to Pharmacological Thromboprophylaxis for Prevention of Venous Thromboembolism in Surgical Inpatients. Ann Surg 2024; 279:29-36. [PMID: 37753655 PMCID: PMC10727201 DOI: 10.1097/sla.0000000000006096] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/28/2023]
Abstract
OBJECTIVE To compare the rate of venous thromboembolism (VTE) in surgical inpatients with pharmacological thromboprophylaxis and additional graduated compression stockings (GCSs) versus pharmacological thromboprophylaxis alone. BACKGROUND Surgical inpatients have elevated VTE risk; recent studies cast doubt on whether GCS confers additional protection against VTE, compared with pharmacological thromboprophylaxis alone. METHODS The review followed "Preferred Reporting Items for Systematic Reviews and Meta-analyses" guidelines using a registered protocol (CRD42017062655). The MEDLINE and Embase databases were searched up to November 2022. Randomized trials reporting VTE rate after surgical procedures, utilizing pharmacological thromboprophylaxis, with or without GCS, were included. The rates of deep venous thrombosis (DVT), pulmonary embolism, and VTE-related mortality were pooled through fixed and random effects. RESULTS In a head-to-head meta-analysis, the risk of DVT for GCS and pharmacological thromboprophylaxis was 0.85 (95% CI: 0.54-1.36) versus for pharmacological thromboprophylaxis alone (2 studies, 70 events, 2653 participants). The risk of DVT in pooled trial arms for GCS and pharmacological thromboprophylaxis was 0.54 (95% CI: 0.23-1.25) versus pharmacological thromboprophylaxis alone (33 trial arms, 1228 events, 14,108 participants). The risk of pulmonary embolism for GCS and pharmacological prophylaxis versus pharmacological prophylaxis alone was 0.71 (95% CI: 0.0-30.0) (27 trial arms, 32 events, 11,472 participants). There were no between-group differences in VTE-related mortality (27 trial arms, 3 events, 12,982 participants). CONCLUSIONS Evidence from head-to-head meta-analysis and pooled trial arms demonstrates no additional benefit for GCS in preventing VTE and VTE-related mortality. GCS confer a risk of skin complications and an economic burden; current evidence does not support their use for surgical inpatients.
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Herring B, Lowen D, Ho P, Hodgson R. A systematic review of venous thromboembolism mechanical prophylaxis devices during surgery. Langenbecks Arch Surg 2023; 408:410. [PMID: 37851108 PMCID: PMC10584699 DOI: 10.1007/s00423-023-03142-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 10/04/2023] [Indexed: 10/19/2023]
Abstract
PURPOSE Hospitalisation and surgery are major risk factors for venous thromboembolism (VTE). Intermittent pneumatic compression (IPC) and graduated compression stockings (GCS) are common mechanical prophylaxis devices used to prevent VTE. This review compares the safety and efficacy of IPC and GCS used singularly and in combination for surgical patients. METHODS Ovid Medline and Pubmed were searched in a systematic review of the literature, and relevant articles were assessed against eligibility criteria for inclusion along PRISMA guidelines. RESULTS This review is a narrative description and critical analysis of available evidence. Fourteen articles were included in this review after meeting the criteria. Results of seven studies comparing the efficacy of IPC versus GCS had high heterogeneity but overall suggested IPC was superior to GCS. A further seven studies compared the combination of IPC and GCS versus GCS alone, the results of which suggest that combination mechanical prophylaxis may be superior to GCS alone in high-risk patients. No studies compared combination therapy to IPC alone. IPC appeared to have a superior safety profile, although it had a worse compliance rate and the quality of evidence was poor. The addition of pharmacological prophylaxis may make mechanical prophylaxis superfluous in the post-operative setting. CONCLUSION IPC may be superior to GCS when used as a single prophylactic device. A combination of IPC and GCS may be more efficacious than GCS alone for high-risk patients. Further high-quality research is needed focusing on clinical relevance, safety and comparing combination mechanical prophylaxis to IPC alone, particularly in high-risk surgical settings when pharmacological prophylaxis is contraindicated.
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Affiliation(s)
- Brianna Herring
- Department of Surgery, University of Melbourne, Epping, Australia
| | - Darren Lowen
- Department of Anaesthesia & Perioperative Medicine, Northern Health, Epping, VIC, 3076, Australia
- Department of Critical Care, Melbourne Medical School, The University of Melbourne, Parkville, Australia
| | - Prahlad Ho
- Department of Haematology, Northern Health, Epping, VIC, 3076, Australia
- Australian Centre for Blood Diseases, Monash University, Melbourne, Australia
- Department of Medicine, Northern Health, University of Melbourne, Heidelberg, Australia
| | - Russell Hodgson
- Department of Surgery, University of Melbourne, Epping, Australia.
- Department of Surgery, Northern Health, Epping, VIC, 3076, Australia.
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Johnsen SP, Jensen M, Münster AM, Frost L, Harboe L, Poulsen PB, Albertsen IE, Vinter N, Grove EL, Larsen TB. Small-Area Analysis of Treatment and Clinical Outcomes in Patients with Venous Thromboembolism in Denmark: A Nationwide Cohort Study. Thromb Haemost 2023; 123:978-988. [PMID: 37054981 DOI: 10.1055/a-2073-4336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/15/2023]
Abstract
OBJECTIVES To investigate geographical variation in initiation and extended treatment with anticoagulants and clinical outcomes among patients hospitalized with first-time venous thromboembolism (VTE) in Denmark between 2007 and 2018. METHODS Using nationwide health care registries, we identified all patients with a first-time VTE hospital diagnosis supported by imaging data from 2007 to 2018. Patients were grouped according to residential region (5) and municipality (98) at the time of VTE diagnosis. Cumulative incidence of initiation of and extended (beyond 365 days) anticoagulation treatment as well as clinical outcomes, including recurrent VTE, major bleeding, and all-cause death, were assessed. Sex- and age-adjusted relative risks (RRs) of the outcomes were computed when comparing across individual regions and municipalities. Overall geographic variation was quantified by computing the median RR. RESULTS We identified 66,840 patients with a first-time VTE hospitalization. A difference in initiation of anticoagulation treatment of more than 20 percentage points between regions was observed (range: 51.9-72.4%, median RR: 1.09, 95% confidence interval [CI]: 1.04-1.13). Variation was also observed for extended treatment (range: 34.2-46.9%, median RR: 1.08, 95% CI: 1.02-1.14). The cumulative incidence of recurrent VTE ranged from 3.6 to 5.3% at 1 year (median RR: 1.08, 95% CI: 1.01-1.15). The difference remained after 5 years, and variation was also observed for major bleeding (median RR: 1.09, 95% CI: 1.03-1.15), whereas it appeared smaller for all-cause mortality (median RR: 1.03, 95% CI: 1.01-1.05). CONCLUSION Substantial geographical variation in anticoagulation treatment and clinical outcomes occurs in Denmark. These findings indicate a need for initiatives to ensure uniform high-quality care for all VTE patients.
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Affiliation(s)
- Søren P Johnsen
- Department of Clinical Medicine, Danish Center for Clinical Health Services Research, Aalborg University and Aalborg University Hospital, Aalborg, Denmark
| | - Martin Jensen
- Department of Clinical Medicine, Danish Center for Clinical Health Services Research, Aalborg University and Aalborg University Hospital, Aalborg, Denmark
- Aalborg Thrombosis Research Unit, Aalborg University, Aalborg, Denmark
| | - Anna Marie Münster
- Unit for Thrombosis Research, Hospital of South West Jutland, Esbjerg, Denmark
| | - Lars Frost
- Diagnostic Centre, University Research Clinic for Innovative Patient Pathways, Silkeborg Regional Hospital, Silkeborg, Denmark
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
| | | | | | - Ida E Albertsen
- Aalborg Thrombosis Research Unit, Aalborg University, Aalborg, Denmark
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Nicklas Vinter
- Department of Clinical Medicine, Danish Center for Clinical Health Services Research, Aalborg University and Aalborg University Hospital, Aalborg, Denmark
- Diagnostic Centre, University Research Clinic for Innovative Patient Pathways, Silkeborg Regional Hospital, Silkeborg, Denmark
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Erik L Grove
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Torben B Larsen
- Aalborg Thrombosis Research Unit, Aalborg University, Aalborg, Denmark
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
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Sahle BW, Pilcher D, Peter K, McFadyen JD, Litton E, Bucknall T. Mortality data from omission of early thromboprophylaxis in critically ill patients highlights the importance of an individualised diagnosis-related approach. Thromb J 2023; 21:59. [PMID: 37221578 DOI: 10.1186/s12959-023-00499-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 05/03/2023] [Indexed: 05/25/2023] Open
Abstract
BACKGROUND Venous thromboembolism (VTE) prophylaxis is effective in reducing VTE events, however, its impact on mortality is unclear. We examined the association between omission of VTE prophylaxis within the first 24 h after intensive care unit (ICU) admission and hospital mortality. METHODS Retrospective analysis of prospectively collected data from the Australian New Zealand Intensive Care Society Adult Patient Database. Data were obtained for adult admissions between 2009 and 2020. Mixed effects logistic regression models were used to evaluate the association between omission of early VTE prophylaxis and hospital mortality. RESULTS Of the 1,465,020 ICU admissions, 107,486 (7.3%) did not receive any form of VTE prophylaxis within the first 24 h after ICU admission without documented contraindication. Omission of early VTE prophylaxis was independently associated with 35% increased odds of in-hospital mortality (odds ratios (OR): 1.35; 95% CI: 1.31-1.41). The associations between omission of early VTE prophylaxis and mortality varied by admission diagnosis. In patients diagnosed with stroke (OR: 1.26, 95% CI: 1.05-1.52), cardiac arrest (OR: 1.85, 95% CI: 1.65-2.07) or intracerebral haemorrhage (OR: 1.48, 95% CI: 1.19-1.84), omission of VTE prophylaxis was associated with increased risk of mortality, but not in patients diagnosed with subarachnoid haemorrhage or head injury. CONCLUSIONS Omission of VTE prophylaxis within the first 24 h after ICU admission was independently associated with increased risk of mortality that varied by admission diagnosis. Consideration of early thromboprophylaxis may be required for patients with stroke, cardiac arrest and intracerebral haemorrhage but not in those with subarachnoid haemorrhage or head injury. The findings highlight the importance of individualised diagnosis-related thromboprophylaxis benefit-harm assessments.
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Affiliation(s)
- Berhe W Sahle
- School of Nursing and Midwifery, Faculty of Health, Deakin University, Melbourne, VIC, Australia.
- Centre for Quality and Patient Safety Research, Alfred Health Partnership, Institute for Health Transformation, Melbourne, VIC, Australia.
| | - David Pilcher
- Department of Intensive Care, Alfred Hospital, Melbourne, VIC, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Australian and New Zealand Intensive Care Society Centre for Outcome and Resource Evaluation, Melbourne, VIC, Australia
| | - Karlheinz Peter
- Atherothrombosis and Vascular Biology, Baker Heart and Diabetes Institute, Melbourne, VIC, Australia
- Department of Medicine, Central Clinical School, Monash University, Melbourne, VIC, Australia
- Baker Department of Cardiometabolic Health, University of Melbourne, Melbourne, VIC, Australia
- Department of Cardiology, The Alfred Hospital, Melbourne, VIC, Australia
| | - James D McFadyen
- Atherothrombosis and Vascular Biology, Baker Heart and Diabetes Institute, Melbourne, VIC, Australia
- Department of Medicine, Central Clinical School, Monash University, Melbourne, VIC, Australia
- Baker Department of Cardiometabolic Health, University of Melbourne, Melbourne, VIC, Australia
- Department of Clinical Hematology, The Alfred Hospital, Melbourne, VIC, Australia
| | - Edward Litton
- Australian and New Zealand Intensive Care Society Centre for Outcome and Resource Evaluation, Melbourne, VIC, Australia
- Fiona Stanley Hospital, Perth, WA, Australia
- The University of Western Australia, Perth, WA, Australia
| | - Tracey Bucknall
- School of Nursing and Midwifery, Faculty of Health, Deakin University, Melbourne, VIC, Australia
- Centre for Quality and Patient Safety Research, Alfred Health Partnership, Institute for Health Transformation, Melbourne, VIC, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
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Lee A, Durst C, Rezzadeh K, Rajaee S, Penenberg B, Than J. Higher Complication Rate in COVID-19 Recovered Patients Undergoing Primary Total Joint Arthroplasty. J Arthroplasty 2023:S0883-5403(23)00399-6. [PMID: 37105327 PMCID: PMC10127742 DOI: 10.1016/j.arth.2023.04.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 04/13/2023] [Accepted: 04/17/2023] [Indexed: 04/29/2023] Open
Abstract
BACKGROUND There is limited data reviewing complication risks associated with total joint arthroplasty (TJA) after recovering from COVID-19. This study evaluated complications within 90 days of TJA in patients who had a COVID-19 diagnosis at varying intervals prior to surgery vs a non-COVID-19 cohort. METHODS A large national database was used to identify patients diagnosed with COVID-19 in the six months prior to total hip arthroplasty (THA) or total knee arthroplasty (TKA). The incidence of complications within 90 days of surgery was recorded and compared to a COVID-19 negative control group matched 1:3 for age range in 5-year intervals, Charlson Comorbidity Index, and sex. There were 7,780 patients included in the study; 5,840 (75.1%) never diagnosed with COVID-19, 1,390 (17.9%) who had a COVID-19 diagnosis 0 to 3 months prior to surgery, and 550 (7.1%) who had a COVID-19 diagnosis 3 to 6 months prior to surgery. RESULTS When compared to their COVID negative controls, patients who had a COVID-19 diagnosis 0 to 3 months prior to surgery had significantly higher rates of re-admission (14.0 vs 11.1%, P=.001), pneumonia (2.2 vs 0.7%, P<.001), deep vein thrombosis (3.3 vs 1.9%, P=.001), kidney failure (2.4 vs 1.4%, P=.006), and acute respiratory distress syndrome (1.4 vs 0.7%, P=.01). Patients who had a COVID-19 diagnosis 3 to 6 months prior to surgery had significantly higher rates of pneumonia (2.0 vs 0.7%, P=.002) and deep vein thrombosis (3.6 vs 1.9%, P=.005) when compared to their COVID negative controls. CONCLUSION Patients diagnosed with COVID-19 within three months prior to TJA have an increased risk of 90-day postoperative complications. Risk for pneumonia and deep vein thrombosis remains elevated even when surgery was performed as far as 3 to 6 months after COVID-19 diagnosis.
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Affiliation(s)
- Anderson Lee
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, 444 S San Vicente Blvd #603, Los Angeles, CA, 90048.
| | - Caleb Durst
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, 444 S San Vicente Blvd #603, Los Angeles, CA, 90048
| | - Kevin Rezzadeh
- St. Joseph's University Medical Center, Department of Orthopaedic Surgery, 703 Main St., Paterson, NJ, 07503
| | - Sean Rajaee
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, 444 S San Vicente Blvd #603, Los Angeles, CA, 90048
| | - Brad Penenberg
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, 444 S San Vicente Blvd #603, Los Angeles, CA, 90048
| | - Justin Than
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, 444 S San Vicente Blvd #603, Los Angeles, CA, 90048
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Bakhsh E, Shaban M, Al Subaie S, Al Moshary M, AlSheef M. Exploring the Clinical Efficacy of Venous Thromboembolism Management in Saudi Arabian Hospitals: An Insight into Patient Outcomes. J Pers Med 2023; 13:jpm13040612. [PMID: 37108998 PMCID: PMC10141716 DOI: 10.3390/jpm13040612] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 03/24/2023] [Accepted: 03/29/2023] [Indexed: 04/03/2023] Open
Abstract
Venous thromboembolism (VTE) is a common condition that can recur, leading to multiple therapeutic strategies to prevent it. The aim of this study was to explore the clinical efficacy of VTE management in Saudi Arabian hospitals and to gain insights into patient outcomes. A retrospective single-center study was conducted that retrieved the data of all patients with VTE registered from January 2015 to December 2017. Patients of all age groups were included if they attended the thrombosis clinic at KFMC during the data collection period. The study analyzed the various therapeutic strategies used for VTE and their effect on patient outcomes. The results showed that 14.6% of the patients had provoked VTE, with a higher incidence among females and younger patients. The most commonly prescribed treatment was combination therapy, followed by warfarin, oral anticoagulants, and factor Xa inhibitor. Despite being prescribed treatment, 74.9% of the patients experienced recurrence of VTE. There was no associated risk factor for recurrence in 79.9% of the patients. Thrombolytic therapy and catheter-directed thrombolysis were found to be associated with a lower risk of VTE recurrence, while anticoagulation therapy, including oral anticoagulants, was associated with a higher risk. Vitamin K antagonist (warfarin) and factor Xa inhibitor (rivaroxaban) had a significant positive association with VTE recurrence, while the use of a direct thrombin inhibitor (dabigatran) showed a lower risk, but it was not statistically significant. The results of the study highlight the need for further research to determine the most effective therapeutic strategy for VTE management in Saudi Arabian hospitals. The findings also suggest that anticoagulation therapy, including oral anticoagulants, may increase the risk of VTE recurrence, while thrombolytic therapy and catheter-directed thrombolysis may lower the risk.
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Affiliation(s)
- Ebtisam Bakhsh
- Clinical Sciences Department, College of Medicine, Princess Nourah bint Abdulrahman University, Riyadh 11564, Saudi Arabia
| | - Mostafa Shaban
- Community Health Nursing Department, College of Nursing, Jouf University, Sakaka 72388, Saudi Arabia
| | - Sarah Al Subaie
- Medical Laboratory Scientific Officer, Ministry of Health, Riyadh 11671, Saudi Arabia
| | - May Al Moshary
- Department of Basic Science, College of Medicine, Princess Nourah bint Abdulrahman University, P.O. Box 84428, Riyadh 11671, Saudi Arabia
| | - Mohammed AlSheef
- Department of Medical Specialties, King Fahad Medical City, Riyadh 11671, Saudi Arabia
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8
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The Use of Medical Imaging Request Forms as Trigger Tools to Detect Intra-Hospital Adverse Events: A Pilot Study. J Belg Soc Radiol 2022; 106:106. [DOI: 10.5334/jbsr.2897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 10/27/2022] [Indexed: 11/11/2022] Open
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Chee A, Bortz H, Yip J, McFadyen JD. Improving compliance with venous thromboembolism prophylaxis guidelines in obese inpatients. Intern Med J 2022; 52:1638-1642. [PMID: 36100562 DOI: 10.1111/imj.15899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 07/27/2022] [Indexed: 11/29/2022]
Abstract
Obesity is a well-recognised risk factor for venous thromboembolism, and increased dosing of pharmacological prophylaxis is recommended in obese inpatients. We performed a clinical decision support intervention by adjusting order sentences of prophylactic enoxaparin within our electronic medical records, which significantly improved appropriate dosing for thromboprophylaxis in obese inpatients at our institution.
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Affiliation(s)
- Adrian Chee
- Department of Haematology, Alfred Health, Melbourne, Victoria, Australia
| | - Hadley Bortz
- Department of Pharmacy, Alfred Health, Melbourne, Victoria, Australia
| | - Jarrod Yip
- Department of Pharmacy, Alfred Health, Melbourne, Victoria, Australia
| | - James D McFadyen
- Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia.,Atherothrombosis and Vascular Biology Program, Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
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10
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Shen J, Casie Chetty S, Shokouhi S, Maharjan J, Chuba Y, Calvert J, Mao Q. Massive external validation of a machine learning algorithm to predict pulmonary embolism in hospitalized patients. Thromb Res 2022; 216:14-21. [DOI: 10.1016/j.thromres.2022.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 05/26/2022] [Accepted: 05/30/2022] [Indexed: 10/18/2022]
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Narayan SW, Gad F, Chong J, Chen VM, Patanwala AE. Preventability of Venous Thromboembolism in Hospitalised Patients. Intern Med J 2021; 53:577-583. [PMID: 34719859 DOI: 10.1111/imj.15600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 10/18/2021] [Accepted: 10/26/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Hospital-acquired venous thromboembolism (VTE) is a major cause of morbidity and mortality. AIM Our study aimed to determine the proportion of patients with hospital-acquired VTE that are preventable. METHODS This was a retrospective study of patients in two tertiary care hospitals in Sydney, Australia. Data were collected for patients with hospital-acquired VTE based on ICD-10-AM coding from January 2018 to May 2020. Patients were classified as low, moderate or high risk of developing a VTE during hospitalization based on demographic and clinical factors. A hospital-acquired VTE was considered to be potentially preventable if there was suboptimal prophylaxis in the absence of contraindications. Suboptimal therapy included at least one of the following related to VTE prophylaxis: low dose, missed dose (prior to developing a VTE), suboptimal drug, and delayed start (>24 hours from admission). RESULTS There were 229 patients identified with VTE based on ICD-10-AM coding. A subset of 135 were determined to have actual hospital-acquired VTEs. Of these, there were no patients at low risk, 64% (87/135) at moderate risk, and 44% (48/135) at high risk of developing a VTE. Most patients (65%, n=88/135) had one or more contraindications to receive recommended prophylaxis. Overall, the proportion of patients who received suboptimal prophylaxis was 11% (15/135). CONCLUSION Approximately, 1 in 10 hospital-acquired VTE are preventable. Hospitals should focus on measuring and reporting VTE that are preventable to provide a more accurate measure of the burden of VTEs that can be reduced by improving care. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Sujita W Narayan
- School of Pharmacy, Faculty of Medicine and Health, University of Sydney, Australia
| | - Fady Gad
- Royal Prince Alfred Hospital, Sydney, Australia
| | - Julianne Chong
- Concord Repatriation General Hospital, Sydney, Australia
| | - Vivien M Chen
- Concord Repatriation General Hospital, Sydney, Australia.,Concord Clinical School, Faculty of Medicine and Health, University of Sydney, Australia
| | - Asad E Patanwala
- School of Pharmacy, Faculty of Medicine and Health, University of Sydney, Australia.,Royal Prince Alfred Hospital, Sydney, Australia
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12
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Saikali M, Tanios A, Saab A. Evaluation of a Broad-Spectrum Partially Automated Adverse Event Surveillance System: A Potential Tool for Patient Safety Improvement in Hospitals With Limited Resources. J Patient Saf 2021; 17:e653-e664. [PMID: 29166298 DOI: 10.1097/pts.0000000000000442] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The aim of the study was to evaluate the sensitivity and resource efficiency of a partially automated adverse event (AE) surveillance system for routine patient safety efforts in hospitals with limited resources. METHODS Twenty-eight automated triggers from the hospital information system's clinical and administrative databases identified cases that were then filtered by exclusion criteria per trigger and then reviewed by an interdisciplinary team. The system, developed and implemented using in-house resources, was applied for 45 days of surveillance, for all hospital inpatient admissions (N = 1107). Each trigger was evaluated for its positive predictive value (PPV). Furthermore, the sensitivity of the surveillance system (overall and by AE category) was estimated relative to incidence ranges in the literature. RESULTS The surveillance system identified a total of 123 AEs among 283 reviewed medical records, yielding an overall PPV of 52%. The tool showed variable levels of sensitivity across and within AE categories when compared with the literature, with a relatively low overall sensitivity estimated between 21% and 44%. Adverse events were detected in 23 of the 36 AE categories defined by an established harm classification system. Furthermore, none of the detected AEs were voluntarily reported. CONCLUSIONS The surveillance system showed variable sensitivity levels across a broad range of AE categories with an acceptable PPV, overcoming certain limitations associated with other harm detection methods. The number of cases captured was substantial, and none had been previously detected or voluntarily reported. For hospitals with limited resources, this methodology provides valuable safety information from which interventions for quality improvement can be formulated.
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Affiliation(s)
| | - Alain Tanios
- Emergency Department, Lebanese Hospital Geitaoui-University Medical Center, Beirut, Lebanon
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Rochefort CM, Abrahamowicz M, Biron A, Bourgault P, Gaboury I, Haggerty J, McCusker J. Nurse staffing practices and adverse events in acute care hospitals: The research protocol of a multisite patient-level longitudinal study. J Adv Nurs 2020; 77:1567-1577. [PMID: 33305473 PMCID: PMC7898788 DOI: 10.1111/jan.14710] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 11/16/2020] [Indexed: 12/27/2022]
Abstract
Aims We describe an innovative research protocol to: (a) examine patient‐level longitudinal associations between nurse staffing practices and the risk of adverse events in acute care hospitals and; (b) determine possible thresholds for safe nurse staffing. Design A dynamic cohort of adult medical, surgical and intensive care unit patients admitted to 16 hospitals in Quebec (Canada) between January 2015–December 2019. Methods Patients in the cohort will be followed from admission until 30‐day postdischarge to assess exposure to selected nurse staffing practices in relation to the subsequent occurrence of adverse events. Five staffing practices will be measured for each shift of an hospitalization episode, using electronic payroll data, with the following time‐varying indicators: (a) nursing worked hours per patient; (b) skill mix; (c) overtime use; (d) education mix and; and (e) experience. Four high‐impact adverse events, presumably associated with nurse staffing practices, will be measured from electronic health record data retrieved at the participating sites: (a) failure‐to‐rescue; (b) in‐hospital falls; (c) hospital‐acquired pneumonia and; and (d) venous thromboembolism. To examine the associations between the selected nurse staffing exposures and the risk of each adverse event, separate multivariable Cox proportional hazards frailty regression models will be fitted, while adjusting for patient, nursing unit and hospital characteristics, and for clustering. To assess for possible staffing thresholds, flexible non‐linear spline functions will be fitted. Funding for the study began in October 2019 and research ethics/institutional approval was granted in February 2020. Discussion To our knowledge, this study is the first multisite patient‐level longitudinal investigation of the associations between common nurse staffing practices and the risk of adverse events. It is hoped that our results will assist hospital managers in making the most effective use of the scarce nursing resources and in identifying staffing practices that minimize the occurrence of adverse events.
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Affiliation(s)
- Christian M Rochefort
- School of Nursing, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, QC, Canada.,Centre de recherche Charles-LeMoyne - Saguenay-Lac-Saint-Jean sur les innovations en santé, Longueuil, QC, Canada.,Centre de recherche du Centre hospitalier universitaire de Sherbrooke, Sherbrooke, QC, Canada
| | - Michal Abrahamowicz
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, QC, Canada.,Department of Epidemiology, Biostatistics and Occupational Health, Faculty of Medicine, McGill University, Montreal, QC, Canada
| | - Alain Biron
- McGill University Health Centre, Montréal, QC, Canada.,Ingram School of Nursing, McGill University, Montréal, QC, Canada
| | - Patricia Bourgault
- School of Nursing, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, QC, Canada.,Centre de recherche du Centre hospitalier universitaire de Sherbrooke, Sherbrooke, QC, Canada
| | - Isabelle Gaboury
- Centre de recherche Charles-LeMoyne - Saguenay-Lac-Saint-Jean sur les innovations en santé, Longueuil, QC, Canada.,Centre de recherche du Centre hospitalier universitaire de Sherbrooke, Sherbrooke, QC, Canada.,Département de médecine de famille et de médecine d'urgence, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Jeannie Haggerty
- Department of Family Medicine, McGill University, Montreal, QC, Canada.,St. Mary's Research Centre, Montréal, QC, Canada
| | - Jane McCusker
- Department of Epidemiology, Biostatistics and Occupational Health, Faculty of Medicine, McGill University, Montreal, QC, Canada.,St. Mary's Research Centre, Montréal, QC, Canada
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Guéroult AM, Machin M, Lawton R, Davies AH, Shalhoub J. What does the future hold for mechanical thromboprophylaxis? Phlebology 2020; 36:257-259. [PMID: 33236672 DOI: 10.1177/0268355520975599] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Aurélien M Guéroult
- Department of Surgery & Cancer, Academic Section of Vascular Surgery, 4615Imperial College London, London, UK.,Imperial Vascular Unit, 8946Imperial College Healthcare NHS Trust, London, UK
| | - Matthew Machin
- Department of Surgery & Cancer, Academic Section of Vascular Surgery, 4615Imperial College London, London, UK.,Imperial Vascular Unit, 8946Imperial College Healthcare NHS Trust, London, UK
| | - Rebecca Lawton
- Department of Surgery & Cancer, Academic Section of Vascular Surgery, 4615Imperial College London, London, UK.,Imperial Vascular Unit, 8946Imperial College Healthcare NHS Trust, London, UK
| | - Alun H Davies
- Department of Surgery & Cancer, Academic Section of Vascular Surgery, 4615Imperial College London, London, UK.,Imperial Vascular Unit, 8946Imperial College Healthcare NHS Trust, London, UK
| | - Joseph Shalhoub
- Department of Surgery & Cancer, Academic Section of Vascular Surgery, 4615Imperial College London, London, UK.,Imperial Vascular Unit, 8946Imperial College Healthcare NHS Trust, London, UK
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15
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Perioperative SARS-CoV-2 infections increase mortality, pulmonary complications, and thromboembolic events: A Dutch, multicenter, matched-cohort clinical study. Surgery 2020; 169:264-274. [PMID: 33158548 PMCID: PMC7513767 DOI: 10.1016/j.surg.2020.09.022] [Citation(s) in RCA: 74] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 09/04/2020] [Indexed: 01/30/2023]
Abstract
Background A direct comparison of severe acute respiratory syndrome coronavirus 2 positive patients with a severe acute respiratory syndrome coronavirus 2 negative control group undergoing an operative intervention during the current pandemic is lacking, and a reliable estimate of the assumed difference in morbidity and mortality between both patient categories remains unknown. Methods We included all consecutive patients with a confirmed pre- or postoperative severe acute respiratory syndrome coronavirus 2 positive status (operated in 27 hospitals) and negative control patients (operated in 4 hospitals) undergoing emergency or elective operations. A propensity score-matched comparison of clinical outcomes was performed between severe acute respiratory syndrome coronavirus 2 positive and negative tested patients (control group). Primary outcome was overall 30-day mortality rate between both groups. Main secondary outcomes were overall, pulmonary, and thromboembolic complications. Results In total, 161 severe acute respiratory syndrome coronavirus 2 positive and 342 control severe acute respiratory syndrome coronavirus 2 negative patients were included in this study. The 30-day overall postoperative mortality rate was greater in the severe acute respiratory syndrome coronavirus 2 positive cohort compared with the negative control group (16% vs 4% respectively; P = .007). After propensity score matching, the severe acute respiratory syndrome coronavirus 2 positive group consisted of 123 patients (median 70 years of age [interquartile range 59–77] and 55% male) were compared with 196 patients in the matched control group (median 69 years (interquartile range 58–75] and 53% male). The 30-day mortality rate and risk were greater in the severe acute respiratory syndrome coronavirus 2 positive group compared with the matched control group (12% vs 4%; P = .009 and odds ratio 3.4 [95% confidence interval 1.5–8.5]; P = .005, respectively). Overall, pulmonary and thromboembolic complications occurred more often in severe acute respiratory syndrome coronavirus 2 positive patients (P < .01). Conclusion Patients diagnosed with perioperative severe acute respiratory syndrome coronavirus 2 have an increased risk of 30-day mortality, pulmonary complications, and thromboembolic events. These findings serve as an evidence-based argument to postpone elective surgery and selected emergency cases.
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16
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Chahal R, Alexander M, Yee K, Jun CMK, Dagher JG, Ismail H, Riedel B, Burbury K. Impact of a risk‐stratified thromboprophylaxis protocol on the incidence of postoperative venous thromboembolism and bleeding. Anaesthesia 2020; 75:1028-1038. [DOI: 10.1111/anae.15077] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/03/2020] [Indexed: 12/13/2022]
Affiliation(s)
- R. Chahal
- Department of Cancer Anaesthesia, Peri‐operative and Pain Medicine Peter MacCallum Cancer Centre Melbourne Vic. Australia
- Centre for Integrated Critical Care University of Melbourne Vic. Australia
| | - M. Alexander
- Peter MacCallum Cancer Centre Melbourne Vic. Australia
- Sir Peter MacCallum Department of Oncology University of Melbourne Vic. Australia
| | - K. Yee
- Department of Cancer Anaesthesia, Peri‐operative and Pain Medicine Peter MacCallum Cancer Centre Melbourne Vic. Australia
| | - C. M. K. Jun
- Department of Medicine and Radiology University of Melbourne Vic. Australia
| | - J. G. Dagher
- Department of Medicine and Radiology University of Melbourne Vic. Australia
| | - H. Ismail
- Department of Cancer Anaesthesia, Peri‐operative and Pain Medicine Peter MacCallum Cancer Centre Melbourne Vic. Australia
- Centre for Integrated Critical Care University of Melbourne Vic. Australia
| | - B. Riedel
- Department of Cancer Anaesthesia, Peri‐operative and Pain Medicine Peter MacCallum Cancer Centre Melbourne Vic. Australia
- Sir Peter MacCallum Department of Oncology University of Melbourne Vic. Australia
| | - K. Burbury
- Peter MacCallum Cancer Centre Melbourne Vic. Australia
- Sir Peter MacCallum Department of Oncology University of Melbourne Vic. Australia
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17
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Improving the adoption of optimal venous thromboembolism prophylaxis in critically ill patients: A process evaluation of a complex quality improvement initiative. J Crit Care 2018; 50:111-117. [PMID: 30529419 DOI: 10.1016/j.jcrc.2018.11.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 11/05/2018] [Accepted: 11/21/2018] [Indexed: 11/20/2022]
Abstract
PURPOSE This study evaluated a complex initiative to increase evidence-based use of low molecular weight heparin for venous thromboembolism prophylaxis among adult medical-surgical ICU patients. MATERIALS AND METHODS This study included: quantitative survey and interviews. Participants were healthcare providers within four ICUs. Surveys collected knowledge of evidence underpinning best practice, exposure to the implementation strategies and their perceived utility, and recommendations. The interview expanded on survey topics. Descriptive statistics summarized the data and chi-squared tests were used to compare groups. Qualitative data were analyzed using a blended deductive and inductive coding approach. RESULTS Providers had good knowledge of the evidence (range = 58% to 94%). Pharmacist-to-physician reminders (80%), other reminders (50%), and local guidelines (50%) were the most commonly observed strategies. Local champions (76%), on-site education (74%), and computerized decision support system (69%) were perceived to be most helpful. Interviews elicited five themes: provider roles, perceptions of the implementation strategies, facilitators and barriers to uptake of best practice, and recommendations. Assessment of the implementation strategies varied by professional group. CONCLUSIONS The findings of this process evaluation identified implementation strategies that can improve the use of evidence-informed practices, help interpret outcomes in the context of interventions and guide future quality improvement initiatives.
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18
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Hidden burden of venous thromboembolism after trauma: A national analysis. J Trauma Acute Care Surg 2018; 85:899-906. [DOI: 10.1097/ta.0000000000002039] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Stubbs JM, Assareh H, Curnow J, Hitos K, Achat HM. Incidence of in-hospital and post-discharge diagnosed hospital-associated venous thromboembolism using linked administrative data. Intern Med J 2018; 48:157-165. [PMID: 29139173 DOI: 10.1111/imj.13679] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Revised: 10/08/2017] [Accepted: 11/09/2017] [Indexed: 12/16/2022]
Abstract
BACKGROUND Hospital-associated venous thromboembolism (HA-VTE) is a serious adverse event, preventable with appropriate care during and post-admission. Accurate measurement of in-hospital and post-discharge incidences is essential for implementation and evaluation of prevention strategies and monitoring. AIMS To estimate in-hospital and post-discharge diagnosed VTE, trends and risk factors. METHODS This was a population-based study in New South Wales, Australia, using linked hospital admission and emergency department data for 2010-2013 of adult patients with a minimum stay of 48 h. HA-VTE were diagnosed in-hospital or post-discharge (within 90 days). Multi-level modelling schemes produced adjusted rates and ratios for patient, admission and hospital-related characteristics. RESULTS From 1 865 059 admissions, the HA-VTE incidence rate was 9.7 per 1000 admissions; 71% were diagnosed post-discharge, and 4.3% died with a greater risk for VTE diagnosed in hospital compared to post-discharge (8.4% vs 2.6%, P < 0.001). Compared with surgical patients, medical patients developed fewer HA-VTE (IRR = 0.60, 95% CI: 0.58-0.63) but were more likely to be diagnosed post-discharge (OR = 2.19; 95% CI: 2.00-2.40). HA-VTE increased 6.5% over the period, driven by the 44% increase in in-hospital diagnoses and not by the 9% decrease in post-discharge diagnoses. CONCLUSIONS HA-VTE is a continuing burden, and diagnosis after recent hospital discharge is notably high. Incidence varies across patients and facilities, highlighting the need for individual VTE risk assessment. Inclusive measures and routine monitoring of HA-VTE incidence and mortality are essential for implementing best practice and assessing effectiveness of prevention strategies.
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Affiliation(s)
- Joanne M Stubbs
- Epidemiology and Health Analytics, Western Sydney Local Health District, Westmead, New South Wales, Australia
| | - Hassan Assareh
- Epidemiology and Health Analytics, Western Sydney Local Health District, Westmead, New South Wales, Australia
| | - Jennifer Curnow
- Department of Haematology, Westmead Hospital, Westmead, New South Wales, Australia
| | - Kerry Hitos
- Westmead Research Centre for Evaluation of Surgical Outcomes, Westmead Hospital, Westmead, New South Wales, Australia.,Discipline of Surgery, The University of Sydney, Sydney, New South Wales, Australia
| | - Helen M Achat
- Epidemiology and Health Analytics, Western Sydney Local Health District, Westmead, New South Wales, Australia
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